Childhood Anxiety: The New Epidemic

Anxiety is the most common, chronic, costly emotional disorder in the U.S. (NIMH) and in 16 of 17 countries (WHO-2004). Moreover, the lifetime diagnosis of anxiety or depression among children aged 6 to 17 years increased from 5.4% in 2003 to 8.4% in 2011–2012. Current anxiety or depression increased from 4.7% in 2007 to 5.3% in 2011–2012 ( Journal of Developmental & Behavioral Pediatrics: June 2018 – Volume 39 – Issue 5 – p 395–403. American Academy of Pediatrics). Foxman (2019) attributes the current state of affairs due to the influence of the post 9-11 world & “war on terrorism,” media  information overload & perceived threats,  and the economy.

“Normal” Anxiety is a physiological response that serves a survival function by alerting individuals to a potential life-threatening/dangerous situation. It can be a healthy emotion—it forces us to focus on our problems, and work hard to solve them. But sometimes, anxiety grows out of control, and does just the opposite. It cripples our ability to solve problems. When this happens, irrational thoughts often play a role. Pathological anxiety occurs when this survival response becomes generalized to situations that are not dangerous or life threatening and/or the intensity, frequency, and duration of response is out of proportion the situation.

Children grow/develop a sense of self through reflected appraisals from significant others (i.e. parents, teachers, peers). Parents,’, teachers, and peers’ faces act as mirrors and reflect back to children how they feel about them or how children make them feel. Positive reflections build an internalized sense of security and confidence while negative reflections build a negative sense of self. Exacerbating this natural process is the fact that about 20% of children have biological sensitivities that predispose them to developing anxiety under conditions like those cited above. In addition, since executive functions (EF), which have the role of regulating thinking and emotions, are developmentally the last part of the brain to fully mature (between 18 to 20 years of age), important EF like inhibition and emotional control are not fully available to “put on the brakes” when stimulation is too intense to digest. 

As a result, more children are presenting with separation anxiety that manifests itself as school refusal, generalized anxiety disorder with its’ somatic symptoms, panic disorder, and obsessive compulsive disorder. Therapeutic approaches include psychoanalytic, cognitive behavioral, as well as mindfulness and, when needed, medication. For parents and teachers, the fundamental principle governing the exposure of children to an overwhelming amount of stimulation is to consider limiting the demands by regulating the quantity and speed with which information is presented.  This includes media use which has become an increasingly larger factor in the development of worry.

While everyone experiences anxiety under certain conditions, when nervousness becomes frequent, intense, and occurs in situations where anxiety would be unexpected or the degree of anxiety is out of proportion to the events, it is time to consider speaking with a professional.


Important Facts When Testing for Learning Disorders

When testing to determine the presence of a specific learning disability (SLD), it is important to remember certain key facts.

First, it is essential to have a clear definition of a SLD. The accepted definition stated in the Individuals with Disabilities Act (IDEA) is:  “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.” Such term “includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.”  That is, there must be evidence of a cognitive processing deficit. It is important that the deficit be manifested functionally such that it clearly interferes with learning and performance. Moreover, the deficit in ability must be related theoretically with an academic subject that relies on this skill for success.

Second, there are times when the normative ability and achievement data do not match. For example, cognitive ability testing may indicate Average skills while achievement testing yields Above Average skills. Here, it is essential to keep in mind that overall ability scores like the IQ only explain 50% of the variations obtained. In the instance where achievement exceeds ability, other factors like good instruction, tutoring, practice, and the acquisition of compensatory strategies can result in better performance than would be expected given the Average ability testing. In addition, an unfortunate artifact of achievement test batteries is that the content of the items may underrepresent the difficulty level of the core curriculum, resulting in higher achievement scores that are discrepant from the classroom functional data.  This situation, which has become more and more common, has been informally referred to as a curriculum-based learning disability. That is, the difficulty level of the curriculum overpowers some students’ ability to perform adequately even when that ability is Average. While lower achievement scores traditionally evoke thoughts of a learning disorder, they may also signal deficient executive function skills that interfere with accessing an individual’s full abilities. For example, the deficits in encoding and retrieving information efficiently in the short or long term may signal EF problems that look like a SLD.

The Pattern of Strengths and Weaknesses (PSW) approach to identifying a SLD is the most comprehensive method in that it includes normative data in the areas of ability and achievement, executive functions, and functional data. Unlike other methods, PSW does not rely solely on a formula and, instead, leans heavily on the experience, acumen, and clinical judgment of the professional evaluator to integrate all of the available information to make the best diagnosis possible.

The Emotional Demands of Parent/IEP Meetings on Professionals: Managing Toxic Induced Emotions

School professionals and parents are constantly engaged in a process of reciprocal emotional exchanges which often go unnoticed. Yet, the power of these induced emotions can drive either constructive or destructive outcomes depending on whether the team can accurately “read” what is needed to move progressively forward.

A common example of how induced emotions can influence the outcome of a meeting (and the subsequent relationship with a parent) is when teachers, administrators, or child study team members innocently seek to convey to parents the difficulties they are experiencing with their children without first anticipating the parental response. Some parents will respond to reports about their children’s struggles with feelings of overwhelming anxiety, despair, fear, or anger. The latter occurs when parents are presented with information in a manner that feels assaultive to them. That is, they are hearing that their child is not performing adequately academically or behaviorally with the implication that they need to do something about it. These same parents may already know about their child’s issues, have struggled with them, and felt as equally perplexed, frustrated, or defeated as the professionals after unsuccessful attempts at addressing the problems. Parents who feel inadequate to the task look to the school team to come up with solutions. Some may respond with panic, shame, or embarrassment, viewing their children’s problems as representative of their failures as parents. Others will feel the need to respond to the perceived attack with a counterattack meant to deflect the onslaught of the intolerable feelings induced by the school team. In these instances, parents may aggressively inquire as to whether the team has followed the IEP, and want to know what they plan to do to further address the problems. When parents react in a defensive/combative rather than collaborative manner, the school team, in turn, may resonate with the emotions induced by the parent and become frustrated and angry at requests to do more, feeling that their efforts to date were not appreciated or recognized and not feeling disposed to give. Instead, their anger may result in behaviors that will only be experienced as being withholding which, in turn, will heighten the need for the team to do more.

Professionals who hope to have a positive outcome often need to give the emotions induced by parents the “right turn.” This requires first being aware that you are “under the influence” of emotional contagion and stop to examine those feelings before responding. Holding the induced emotions is challenging because the feelings are often uncomfortable or intolerable and they drive an urge for discharge. Yet, it is these very feelings that give you the diagnostic information you need to generate an accurate emotional response. They provide a roadmap about what to say or do if you can only tolerate holding them long enough to extract the information you need.

How do you give these contagious and often toxic emotions the “right turn”? The team members need to accept the fact that, whether they like it or not, they will be exposed to these feelings and resign themselves to allowing those feelings to wash over them, remove the toxic components, and use the remainder to construct an accurate emotional response. For example, parents respond to a report about their child by implying that the team hasn’t done an adequate job and needs to do more. The team has the choice of becoming defensive and listing every single intervention attempted or accepting the parents’ feeling without agreeing with it. It is important to be willing to hear and take seriously parents’ perspective because without this first step, there is little chance that they will be willing to hear opposing views. A response that may serve to begin to bridge the gap may be, “If the situation were as you described it, I would certainly understand your position. However, the situation is actually different.”  Being accurately emotionally responsive requires that we tolerate the toxic induced emotions and use them to craft a response that addresses the emotions expressed. While this seems like a tall order, it is the best way to try to drain off toxic emotions and prevent them from morphing into something worse.


The Obstacles to Accurately Identifying a Specific Learning Disability: Limitations of Achievement Test Batteries

Child Study Team (CST) and private practice professionals who are tasked with determining the presence of a specific learning disability (SLD) have acknowledged a growing awareness that limitations of widely used achievement batteries pose an obstacle to accurately identifying the presence of a SLD.

Current achievement test batteries do not adequately mirror the core curriculum used in the classroom. As a result, students who are evaluated to determine eligibility may test out in the Average range despite having significant functional problems in the classroom. For example, students may earn Average range scores on the Pseudoword Decoding subtest of the WIAT-111 but have major problems in decoding. Similarly, that same student may perform in an Average range on the Oral Reading Fluency subtest, but exhibit significant problems with fluency in the classroom.

It is important to remember that the major test batteries offer a sample of academic skills for assessment. When the test material is easier than the core curriculum students are tasked to master, they may be deemed ineligible for support services because of their Average or Above Average range scores. Given this knowledge, professionals at school and even privately may wish to consider testing that is more geared to the curriculum. Moreover, following the general principle of amassing multiple data sources, professionals should consider that functional data (i.e. curriculum-based assessment) from the classroom teacher or parent that is different from the testing data should be further investigated. This may mean doing further assessment or formulating an assessment battery from the outset that may give the clearest picture of a student’s strengths and weaknesses. For instance, for the example mentioned above, using the Comprehensive Test of Phonological Processing to assess phonemics and the Gray Oral Reading Test to measure fluency (i.e. accuracy and efficiency) will provide more comprehensive data and present students with test material that is more challenging than either the WIAT-111 or the WJ-IV. Another tool is Easy CBM which measures reading am math skills and is geared to reflect the curriculum.

An interesting phenomenon has evolved as a result of the fact that the core curriculum is in many ways not developmentally grounded. That is, it poses tasks for students to perform that are beyond their developmental maturity. As a result, a participant at a workshop I gave on identifying learning disabilities proposed that another category of learning disability be considered: curriculum-based learning disorder. That is, a learning disorder that has its roots in the discrepancy between students’ developmental capacity to absorb the curriculum and the expectation that they should be able to master it, making them appear to be learning disordered. Are we creating learning disorders as a byproduct of the curriculum?

The Core-Selective Evaluation Process (C-SEP): Further Support for the Pattern of Strengths and Weaknesses Approach (PSW) for Identifying Learning Disabilities

The recent release of “Using the Core-Selective Evaluation Process (C-SEP) With the Woodcock-Johnson IV: From Theory to Practice (Assessment Service Bulletin Number 11,” from Houghton Mifflin was a welcome sight as it provides further support for the use of the PSW model which I have been writing about for the past two years.

C-SEP mirrors the PSW principles espoused by Flanagan, Ortiz, and others as well as the Cross-Battery Assessment (XBA) procedures described by the same authors. Specifically, C-SEP utilizes the WJ IV family of instruments to gather normative data describing students’ neurocognitive profiles. Thus, both the Wechsler and the WJ IV families of instruments are tools available to diagnose a learning disability. Both approaches utilize similar principles: (1) students would have had to receive appropriate instruction to rule out lack of instruction as a variable; (2) multiple sources of information (i.e. curriculum-based assessment, grades, work samples, test scores) must be sought in justifying a referral for testing and developing a hypothesis that drives the assessment process; (3) linkages between identified processing and achievement deficits must exist; and (4) other factors (i.e. physical or intellectual disabilities; social-emotional disorders; environmental or economic disadvantage, and cultural-linguistic factors) must be ruled out. C-SEP offers its own version of XBA when it is important to expand the assessment of specific findings (i.e. administering another subtest to test out an initial finding is recommended when the WJ IV core administration includes only one subtest in a processing area).

One difference I observed is that the PSW model offers a statistical program to analyze normative data that contrasts findings associated with strengths and those with weaknesses to determine if a statistical difference exists. Moreover, the recent expansion of the PSW software includes hundreds of tests and subtests that may be utilized in performing XBA to give a more comprehensive picture of processing and achievement strengths and weaknesses. PSW also includes measures of executive functions to further elaborate on neurocognitive profiles.

Despite the differences, the road ahead appears to be clear: PSW is being recognized as the primary approach for identifying learning disorders. It is now up to legislators and departments of education in states like New Jersey to acknowledge that PSW reflects the best science we have and give child study teams “permission” to move away from the antiquated and flawed eligibility criteria in the current state code.


The Important Functions of Resistance: What Parents, Teachers, and Therapists Need to Know

Parents, teachers, therapists, and employers are often frustrated by the tendency of individuals with whom they must interact to resist doing what is being asked of them, especially when it is clear that being compliant is in their best interest. On the surface, resistances do not seem to make sense. What is the benefit of students not doing their homework or not studying for exams? Why do employees choose to deflect work assignments or fail to follow procedures or rules? The consequences for being non-compliant can be great. It just doesn’t make any sense.

Understanding the survival and communication functions of resistances helps to decipher these seemingly annoying resistances. In fact, for some individuals, not being resistant holds greater personal consequences. Here is what you need to know about resistances.

First of all, resistances are a natural part of human behavior. They have a survival function-i.e. they preserve the ego of the individual by deflecting that which is threatening-which supersedes the more apparent consequences of not doing something. For example, students who find the academic challenges daunting and feel a lack of mastery will find ways to deflect assigned tasks not because they are being oppositional, but, instead, to preserve themselves from the narcissistic assault of not being able to perform as expected. While not trying or not doing holds its own consequences, choosing not to perform with the purpose of shielding one’s ego from the terrifying prospect of failure may be a better alternative or a lesser evil.

Second, resistances have a communication function. The manner in which individuals resist doing something communicates how best to approach them. (Yelling and screaming do little other than getting temporary compliance). Deciphering the function of resistances may require reinforcing the resistance rather than trying to break through them. While reinforcing a resistance may sound “crazy,” it is important to remember that resolving resistances first requires the willingness to consider the following: (1) individuals choose behaviors, even when they seem unreasonable and illogical, for good reasons; (2) understanding the reasons for resistance communicates a readiness to see the others’ perspective; and (3) an unwillingness to consider another’s perspective makes that person unavailable to hear what you have to say.

Here is an example of a common resistance and how tolerating the induced emotions emanating from the resistance and taking the time to understand the functions of the resistance evolve into a strategy for resolving the resistance. Children and adolescents who are coerced by their parents to seeing a therapist may harbor a deep resentment that is expressed by behaviors rather than words that reflect their unwillingness to cooperate with their parents’ plans. That is, they may attend visits, but not speak or engage in repetitive behaviors or oppose in any way possible the efforts of therapists who are viewed as parental surrogates. The power of the resistance may be experienced by parents and therapists alike as frustration and anger-the same feelings the child is experiencing as a result of being forced to do something he or she does not want to do. When the adults allow themselves to tolerate and experience these unpleasant emotions, they can examine and realize they have a communication function. They scream out, “I am not going to cooperate with you!” Recognizing this, therapists can put these unspoken emotions into words, giving the child the experience of being understood. The therapist then becomes someone of value because he/she has deciphered the behavioral resistance. Taking it further, verbalizing this question-“Don’t your parents realize you have no intention of cooperating with them?”-opens up the opportunity for a dialogue about all of the unfairness the child has felt in relation to the parent. Putting the resentment into words starts to melt the resistance as words become the medium of communication instead of behaviors. The therapy can then begin.

To put this another way, resistances are needed to understand the obstacles to individuals’ willingness to perform or behave in ways that express cooperation rather than opposition. What is also needed is a patient interpreter of resistances to do the deciphering and translate what is learned into an emotional communication that helps the resistant individual to move progressively forward rather than stay trapped in an endless repetitive behavioral cycle.

The Neurocognitive Basis for Learning Disabilities and Executive Function Deficits: A Primer for Parents

To understand the obstacles to students’ learning and performance success, you need not look any further than their processing ability and executive function profiles. The key here is to remember that academic subjects are composed of groups of processing abilities that are, in turn, linked with specific executive functions that serve the purpose of cueing or directing the activation of those abilities in the service of performing a task. For example, the primary processing abilities that are part and parcel of reading include phonemic awareness/auditory processing, orthographic/visual processing, nonverbal reasoning (for inference and comprehension), and long-term memory. The executive functions that support the processing abilities involve activation to work, establishing and sustaining a focus, inhibiting the urge to respond to something other than the reading assignment, adequate processing speed, and shifting to allow movement from one part of the reading assignment to another. Any breakdowns in either the processing skills or executive functions will result in reading difficulties.

The strength of a neurocognitive approach lies in breaking down the primary ability areas further into the narrow abilities that comprise each domain. Here is where the detective work begins. For example, language processing is a primary ability area. It is not sufficient to obtain a score from tests on just this primary ability area because within the domain of language processing there are various narrow skills that may be responsible for students’ difficulties. For instance, lexical knowledge is a narrow ability that encompasses the fund of acquired vocabulary a student has stored in long term memory. It is not uncommon for many students to have average or above average ability in this narrow ability area. Yet, in another narrow ability area, verbal reasoning, which is the skill needed to think and write in a more abstract way, these students falter. Thus, they would do better on vocabulary and spelling tests which rely on rote memory, but struggle when it comes to reading comprehension and making the inferences involved in more conceptual thinking.

Getting to the bottom of students’ learning problems requires this kind of detective work which can be thought of a peeling back the layers of an onion where the starting point are the primary abilities in the top layer and then going further to the layers underneath to get to the narrow ability areas that can be interfering with learning and performance.

Similarly, analyzing the many executive functions-brain processes that cue and direct the activation of the abilities-is of equal importance. For example, there are students whose academic abilities are sound. However, deficits in executive functions like attention, activation to work, or inhibition may leave them adrift, relegated to “spacing/zoning out” and to frequent periods of distractibility, all of which causes them to miss out on instruction. Another common problem occurs when students with an adequate vocabulary are unable to generate an adequate amount of verbiage because of problems with the executive function of planning and organization when faced with demands in producing narrative writing. Thus, these students do not have a learning problem (i.e. a learning disability), but have an executive function deficit (i.e. a producing problem). Writing is a complex skill where executive function deficits in the form of students being unable to get the ideas in their heads onto paper are a common complaint.

The most comprehensive and scientifically valid approach to investigating ability and executive functioning deficits is a neuropsychological evaluation. This kind of assessment not only identifies students’ patterns of strengths and weaknesses, but links these to accommodations and instructional practices that target these specific areas. Generating concrete and practical strategies that target a students’ weaknesses offer teachers, parents, and tutors with the most effective ways to address learning and performance problems.